016.29.22 Ark. Code R. 004 - Act 637-Hospital, Physician and Nurse Practitioner Provider Manuals to aff PANS/PANDAS Treatment

Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

272.502 Drug Treatment for Pediatric PANS and PANDAS 6-1-22

A. Effective for dates of service on and after 6/1/2022 drug treatment will be available to all qualifying Arkansas Medicaid beneficiaries when specified conditions are met for one (1) or both of the following conditions:

1. Pediatric acute-onset neuropsychiatric syndrome (PANS),

2. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

B. The drug treatments include off-label drug treatments, including without limitation intravenous immunoglobulin (IVIG).

C. Medicaid will cover drug treatment for PANS or PANDAS under the following conditions:

1. The drug treatment must be authorized under a Treatment Plan; and

2. The Treatment Plan must be established by the approved PANS/PANDAS provider.

D. A Prior Authorization (PA) must be obtained for each treatment. Providers must submit the current Treatment Plan to the Quality Improvement Organization (QIO) along with the request for Prior Authorization. (Add link to AFMC.)

E. The authorized procedure codes and required modifiers are found in the following link:

View or print the procedure codes for Hospital/Critical Access Hospitals/ESRD services, including PANS and PANDAS procedure codes.

252.483 Drug Treatment for Pediatric PANS and PANDAS

A. Effective for dates of service on and after 6/1/2022 drug treatment will be available to all qualifying Arkansas Medicaid beneficiaries when specified conditions are met for one (1) or both of the following conditions:

1. Pediatric acute-onset neuropsychiatric syndrome (PANS),

2. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

B. The drug treatments include off-label treatments, including without limitation intravenous immunoglobulin (IVIG).

C. Medicaid will cover drug treatment for PANS or PANDAS under the following conditions:

1. The drug treatment must be authorized under a Treatment; and

2. The Treatment Plan must be established by the approved PANS/PANDAS provider.

D. A Prior Authorization (PA) must be obtained for each treatment. Providers must submit the current Treatment Plan to the Quality Improvement Organization (QIO) along with the request for Prior Authorization. (Add link to AFMC.)

E. The authorized procedure codes and required modifiers are found in the following link:

View or print the procedure codes for Nurse Practitioner services, including PANS and PANDAS procedure codes.

292.930 Drug Treatment for Pediatric PANS and PANDAS

A. Effective for dates of service on and after 6/1/2022 drug treatment will be available to all qualifying Arkansas Medicaid beneficiaries when specified conditions are met for one (1) or both of the following conditions:

1. Pediatric acute-onset neuropsychiatric syndrome (PANS),

2. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS).

B. The drug treatments include off-label drug treatments, including without limitation intravenous immunoglobulin (IVIG).

C. Medicaid will cover drug treatment for PANS or PANDAS under the following conditions:

1. The drug treatment must be authorized under a Treatment Plan; and

2. The Treatment Plan must be established by the approved PANS/PANDAS provider.

D. A Prior Authorization (PA) must be obtained for each treatment. Providers must submit the current Treatment Plan to the Quality Improvement Organization (QIO) along with the request for Prior Authorization. (Add link to AFMC.)

E. The authorized procedure codes and required modifiers are found in the following link:

View or print the procedure codes for Physician/Independent Lab/CRNA/Radiation Therapy Center services, including PANS and PANDAS procedure codes.

Notes

016.29.22 Ark. Code R. 004

Adopted by Arkansas Register Volume 47 Number 06, Effective 5/30/2022